Student

Name: Corinne Buffo Case: Date: 3/23/20

1. Diagnosis, Referral, Setting, Reimbursement, LOS

- Dx: Pneumonia (secondary dx/hx: CHF, COPD, Type II diabetes, OA, gout, TKA 3ya, morbid
obesity)
- Referral: Physician
- Setting: Salt Lake Transitional Care Unit
- LOS: 3 weeks
- Reimbursement: Medicaid

2. Pragmatic Factors to Consider

- Smoker
- MoCA scores represent mild cognitive deficit (although unsure if this actually has functional
impact)
- Medicaid limits OT visits, skills to be worked on
- Client will be returning to living alone, caring for several pets
- Son is not supportive or consistently at the home
- Complicated medical history with several diagnoses

3. Context: Occupational Profile & Current Occupations

Cultural:      
Physical:      
Social:      
Personal:      
Temporal:      
Virtual:      
Prior Occupations:
     
Current Occupations:
     

4: Top Three Client/Family Goals and Priorities (COPM & imptnc level)
1. Bra/nylons (9), bathing (7), driving at night (9), cleaning (6), cooking (2)
2.      
3.      

5. Diagnosis and Expected Course 6. Scientific Reasoning & Evidence

Pneumonia
-More serious in adults >65 and those with
comorbidities (COPD), these cases will
require longer recovery and hospitalization
- Common symptoms: dyspnea, cough,
fever, chills, fatigue, substernal discomfort,
myalgia
List the barriers to performance typical of this
diagnosis:
- CHF recommendations include fluid restrictions, yet
gout recommendations include increasing fluid intake;
this conflict leads to either increased symptoms in one
of the diseases, or requires medication management for
one or the other (possibly both)
- Later stages of CHF, OA, and COPD can limit ability
to exercise; however, management of his dx’s, such as

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CHF his Type II diabetes, are improved by physical activity
- Fluid buildup in the lungs causes dyspnea, - OA may cause morning stiffness, limits ability to
puts greater workload on heart perform tasks until later in the day
- Low sodium diets and fluid restrictions - Diet is an important factor in many of his dx’s, can be
can reduce overall body fluid, medications a difficult area to make modifications based on budget,
can be taken, exercise can improve life access to food, culture, habits
expectancy and quality of life; no cure - Vision loss in type II diabetes can limit occupations,
- Gradual resumption of activity after an require modifications and strategy use
acute exacerbation can promote function; - Type II diabetes can lead to amputation without
too much too soon may lead to another vigilant skin checks, can have a huge impact on
acute exacerbation occupations and lifestyle
- ~50% dx with heart failure die within 5 - Declines in ability to perform ADLs and have
years of dx; 5.1 million people in U.S have functional mobility as one ages results in decreased life
heart failure expectancy; occupational therapy can address both of
- Physical activity becomes more limited as these areas
individual progresses through stages of - Fall prevention is an extremely important area of OT
cardiovascular disability to assess in older adults; falls are the leading cause of
- Prognosis decreases with age fatal/nonfatal injuries in older adults in a 2013 report by
COPD the CDC
- Involves emphysema and chronic - 50% of individuals with mild cognitive impairment
bronchitis develop dementia in the following 3 years
- Causes difficulty breathing, decrease in
IADL abilities
- As progresses, can cause dyspnea at rest
- no cure, damage caused is irreversible
- medical management and lifestyle changes
can slow progression and maintain ability to
participate in occupations
Information from Pedretti’s,
- More prone to upper respiratory infections https://www.ncbi.nlm.nih.gov/pubmed/29292123
Type II Diabetes
-cataracts and retinal damage can occur,
lead to blindness
- At risk for renal failure, nerve damage,
atherosclerosis, gangrenous infection (often
leads to amputation)
- Varied effect on life expectancy, depends
on how well disease is managed through
diet, exercise, medication, smoking status
OA
-will likely have joint pain, stiffness,
tenderness, limited movement, local
inflammation, and crepitus; symptoms
usually occurs sporadically (have
“good/bad” days)
- Commonly affects DIP, PIP, CMC of
hand; cervical and lumber; MTP of feet;
knees and hips
- Pain and stiffness usually occurs with
activity and is relieved by rest; eventually

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will occur at rest
- No cure, gradual deterioration of cartilage,
symptoms usually managed through
medication, topical agents, surgery
- Morning activities may need to be
modified/assisted with due to greater
stiffness, schedule more meaningful
activities later in day
- Loss of social relationships and cognitive
changes can occur due to psychological
impact of disease
Gout
-Causes sudden and severe pain and
inflammation, commonly affects big toe
- Untreated, can damage joints, limit
mobility, and cause chronic pain, and
kidney stones
- Treatment includes ice/elevation,
increasing fluid intake, decreasing stress,
medication, diet changes, weight loss and
exercise
TKA
-survival rate 89% ten years post-TKA
- Stiffness more common in patients with
primary knee OA

7. Practice Models Guiding Assessment and Rationale

Treatment
1 PEO PEO will be used to consider the home
. environment the client will be returning to at the
end of his stay, and how modifications in the
home and in his occupations can be made to
allow him to return home as safely and
independently as possible. It will also be used to
assess client factors, such as strength, sensation,
and endurance, that can be improved to allow
continued independence in his occupational
participation.
2 Rehabilitation This model will be used during assessment to
. see where task/environment modifications will
need to be made. It will be used in treatment to
implement strategies to improve the client’s
independence and performance in occupations.
For this specific client, strategies will likely
include energy conservation techniques, low
vision strategies, and use of adaptive equipment
for safety in the home.

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3 Lifestyle Redesign This model will be used to assess the client’s
. current routines, habits, occupations, and
lifestyle, and where these can or need to be
modified. His current amount of diagnoses
require vigilance for his health to prevent further
decline. Adding physical exercise to the client’s
daily routine would be an important change to
address, and this model will be used to assess his
willingness to incorporate this activity and find
any motivation he may have to facilitate this.
Other occupations, such as his diet and
medication management, can be incorporated
into this model.

8. Specific Areas of Occupation

What do you know? What do you need to know?
           

9. Performance Skills
What do you know? What do you need to know?
           

10. Performance Patterns-Habits, Routines, Rituals, Roles

What do you know? What do you need to know?
           

11. Activity Demands for the Client Goals and Priorities

What do you know? What do you need to know?
           

12. Client Factors- Values, Beliefs, Spirituality

What do you know? What do you need to know?
           

13. Client Factors- Body Functions & Structures

What do you know? What do you need to know?
           

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 14. Evaluation: What Assessment tools and other means of assessment will you use?
Top Down Assessment: Prioritize one Occupation to observe the client perform

Observed Occupation Rationale/How will you use this information

Dressing
Method/Tool
1. Home evaluation (Rebuilding Together)
2. Medication management (Pillbox Test)
3. Pain (Brief Pain Inventory)
I would like to observe dressing to get more
information on his preferred clothing. This
occupation will also give me information as to
where his barriers in this task are occurring. Is
he having trouble reaching behind him to
unclasp the bra? Does he have difficulty
enduring parts of the task, or the whole task? Is
he having difficulty pinching or manipulating
clothing materials?
Rationale/What is being Assessed
I would want to assess the safety of the client’s
home in regard to his current diagnoses, and
examine where changes may need to be made to
allow him to continue living independently, as
he is very adamant about this. Rebuilding
Together will be useful to include aspects of
lighting for vision, as the client’s vision is
worsening. Rebuilding Together also helps to
prioritize the most essential home modifications,
an important aspect if finances are tight.
With the amount of diagnoses the client has, he
likely has a fair amount of medications.
Assessing his ability to manage these using the
pillbox test will look at an important part of his
ability to remain safely independent at home.
This test will also give information about his
functional cognition, hand sensation, fine motor
abilities, and grip/pinch strength.
I would assess his pain levels to see if this is a
barrier when performing his ADLs that he has
listed he is not satisfied with. Are his pain levels
a factor in showering/bathing? Are they
impacting his ability to perform standing
activities? The inventory will give insight into
where his pain is occurring and what general
activities it is affecting. Diagnoses that are likely
affecting his pain levels are Gout and OA.

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4. Sensation (pain, temperature, light touch)
5. Vision (FOAM SCRAP visual screen)
6. Meal prep/IADL safety/independence (PASS
meal prep (stovetop use))
I would want to test sensation in UE, feet, and
areas affected by his OA. I would want to assess
foot sensation to check for areas of concern for
diabetic neuropathy. His UE sensation would
give information about his ability to perform
tasks requiring fine motor abilities (opening pill
bottles, dressing, etc.). Testing areas affected by
his OA would give me information about any
nerve damage or compression that may be
occurring in these areas. This information will
help to see where task modification may need to
occur, and if client education is needed for skin
checks.
Although we know his vision is worsening, it
would be helpful to assess what areas of his
vision are poor to see where activities will need
modification. It will also help to see if
environment or task modifications need to be
addressed as part of intervention. Does he need
more light in his home? Does he need larger
print during written activities in therapy? Does
his vision contribute to a fall risk in his home?
Although meal prep is not high on his list of
importance on the COPM, it is an important
factor of living independently and safely. I
would use information from the PASS stovetop
use assessment to look at his safety during a
simple meal prep task, and his ability to cook
simple meals for himself independently. I can
also see where he runs into problems, which will
give me areas to focus on and/or modify through
intervention.

15. CPT Evaluation Code: Justification

97167 (High complexity) - Medical background review: Due to an extensive background of
diagnoses, his medical background review will be quite in depth.
- Occupations affected: Client reported 5+ occupations affected on
the COPM, and his diagnoses are likely affecting nearly all of
his ADLs/IADLs
- Clinical Reasoning: Multiple options exist for treatment, and
complex reasoning is necessary to determine how to navigate
intervention with the client’s multiple diagnoses. Assessments
may require modification if symptoms are a barrier, such as poor
vision or OA/gout pain.

16. Projected Outcomes: Type of Outcome

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17. Resources and Team Members

Resources:
- Local gyms/YMCAs
- Arthritis Foundation
Team members:
- Dietician
- Physical Therapy
- Pharmacist

18. Intervention Plan

Barriers Supports
-Son is not a strong social support - Has clear ideas of what he wants to
- Must care for 5 pets; these could also be a fall hazard in his work on in therapy and how he
smaller home prioritizes these tasks (dressing,
- Is to return to living alone bathing, driving, cleaning)
- Likely does not have proper diet and exercise routine to - Motivation to live independently
manage diagnoses and symptoms; this could be a very can be used to maintain/improve
difficult part of his lifestyle to change participation in therapy
- Habit of smoking may be difficult to change - Is returning to a smaller home,
- Must learn to utilize O2 nightly and during exertion decreased amount of space to
maintain

Goals Approach and deficit(s) for each goal

1. LTG: By discharge, client will perform household tasks PEO, rehab; increased fatigue,
with modI, with client self-reporting fatigue level of less decreased strength/endurance
than 3/10. (muscular and cardiovascular),
functional mobility around home and
ability to bend and reach,
manipulating cleaning materials

1a.STG: In 1 week, client will perform household cleaning Rehab; increased fatigue, decreased
tasks with minA, using energy conservation strategies. strength/endurance (muscular and
cardiovascular), ability to bend and
reach, manipulating cleaning
materials, pacing tasks

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1b.STG: In 2 weeks, client will perform household cleaning PEO, Lifestyle Redesign; muscular
tasks with modI for 15 minutes. strength/endurance, cardiovascular
endurance, pacing tasks

2. LTG: By discharge, client will manage medications with Rehab, lifestyle redesign, PEO;
modI. manipulation of pills, attending to
timing and amount, organizing pills

2a. STG: In 1 week, client will demonstrate proper timing of Rehab; attending to timing and
medications utilizing phone alarms with no more than 2 VC. amount

2b. STG: In 2 weeks, client will maintain organized weekly Rehab, lifestyle redesign; organizing
pill box with no more than 1 VC. pills, placing pills in correct time
slots

2. LTG: By discharge, client will perform ADLs with modI. PEO, rehab; muscular
strength/endurance, cardiovascular
endurance, manipulating materials,
standing endurance/balance,
attending to tasks, functional
mobility around the home

3a.STG: In 1 week, client will complete UB dressing with PEO, rehab; muscular
minA, using compensatory techniques. strength/endurance, manipulating
materials

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3b. STG: In 2 weeks, client will shower with modI. Rehab; muscular strength/endurance,
cardiovascular endurance,
manipulating materials, standing
endurance/balance, attending to task

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 19. Treatment Sessions: Plan for first two 45-minute treatment sessions:
1. What will you do? Identify Practice Based on which
Model goal(s)?
Client will be seated in therapy gym with pet care LTG1, STG1a
supplies on table in front of client. Therapist will Rehab, PEO
explain concept of energy conservation to client,
and strategies will be practiced in the task of pet
care. Therapist will interview client about his
current set up at home for caring for his pets. He
will then be educated on A/E to use during pet care
tasks. He will be instructed to practice the following
tasks using A/E: brushing a dog using a brush with
built up handle, feeding animals using ReachaBowl
handled pet bowls, and long handled scoop for kitty
litter. He will be educated on energy conservation
and breathing techniques for use in pet care, such as
taking rest breaks and sitting during giving the dogs
a bath, or using pursed lipped breathing while
taking them on walks. Client will be educated on
how these strategies can be generalized to other
daily tasks, and will be given energy conservation
and breathing technique handouts.
3. What will you do? Identify Practice Based on which
Model goal(s)?
Client will be seated EOB in preparation for Rehab, PEO LTG1, LTG3, LTG3a
dressing activity to improve activity tolerance and
teach compensatory strategies. Client will be
instructed to walk to closet and pick out hosiery and
pants, then return to sitting EOB. He will be
educated on the use of A/E (dressing stick, sock
aid) to dress LB to decrease exertion from bending
down to get clothing over feet and to decrease grip
requirements on clothing materials. He will then be
instructed to return to closet to retrieve bra. He will
be educated on use of bra dressing aid to assist in
donning bra. Client will be instructed to retrieve
shirt from closet and return to sit EOB to don.
Client will be instructed to organize closet so that
frequently worn clothing is around chest level, to
decrease amount of bending and reaching for joint
protection. He will be given necessary level of
assist throughout task. Client will be given handout
for joint protection.

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